Permission Form – General Release/Hold Harmless Agreement for ...

stmatthewsrichmond.org

Permission Form – General Release/Hold Harmless Agreement for ...

Permission FormGeneral Release/Hold Harmless Agreement for St. Matthew’s

Episcopal Church, Vacation Bible School, July 8-12, 2013.

CHILD’S NAME__________________________________________________________

As the parent or legal guardian of ______________________________________ I

agree to the following:

The child listed above has permission to participate in the St. Matthew’s

Episcopal Church Vacation Bible School, from July 8 – 12, 2013.

Without the release and permission of the parent, the above child cannot

participate in St. Matthew’s Episcopal Church Vacation Bible School.

I, the undersigned, request that the Church and Children’s ministry allow the

child to participate in the activity and in consideration thereof, agree to hereby

release and forever discharge the Church, Children’s ministry, their offices,

directors, employees, agents and any parties volunteering on behalf of the

church from all actions, claims, damages of any kind growing out of related

activity.

I acknowledge that this is a full and complete release for all injuries and

damages which the above child may sustain as a result of participating in the

activities.

I authorize the treatment of the child by a qualified and licensed medical

doctor in the event of an emergency which, in the opinion of the attending

physician, may endanger his/her life, cause disfigurement, physical impairment,

or undue physical discomfort if delayed, while said minor is participating in the

activity – including transportation to and from the site. The authority is granted

only after a reasonable attempt has been made to contact me, the parent or

guardian.

Any required medicines to be delivered during VBS. All drugs need to be in their

original package with prescription information.

YOUR SIGNATURE: _______________________________________date_______________


REGISTRATION FOR ST. MATTHEW’S VBS

Child’s Full Name____________________________Nickname _____________

Child’s Age___________Grade enrolled in for Fall 2013__________________

Parent/Guardian’s Name_____________________________________________

Address______________________________________________________________

City______________________________State_________________Zipcode_______

Home Telephone Number:_______________Cell Number:_________________

Home Email Address:_____________________________________________

Home Church (if any) _____________________________________________

Emergency contact person and phone numbers:

________________________________________________________________________

PICK UP INFORMATION: Person responsible for picking this child up each

day

Name:

______________________________________Phone:_________________________

Relationship to child___________________________________________________

PLEASE LIST ANY ALLERGIES OR OTHER CONCERNS THE VBS STAFF SHOULD BE

AWARE OF:

_______________________________________________________________________

The child’s physical limitations are:

________________________________________________________________________

The child’s medications are _______________and taken__________________,

______________________________________________ give permission for St.

Matthew’s Episcopal Church to use the image, voice, quote, or video of

my child, ____________________________________________. St. Matthew’s

Episcopal Church may the image, voice, quote or video of my child at

their discretion, including, but not restricted to, the website, brochures or

other promotional material.

YOUR SIGNATURE:___________________________________Date_______________

PLEASE FILL OUT THE BACK OF THIS FORM

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